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Long-Term, Low-Intensity Warfarin Therapy for the Prevention of Recurrent Venous Thromboembolism
Open accessAbstract
BACKGROUND: Standard therapy to prevent recurrent venous thromboembolism includes 3 to 12 months of treatment with full-dose warfarin with a target international normalized ratio (INR) between 2.0 and 3.0. However, for long-term management, no therapeutic agent has shown an acceptable benefit-to-risk ratio. METHODS: Patients with idiopathic venous thromboembolism who had received full-dose anticoagulation therapy for a median of 6.5 months were randomly assigned to placebo or low-intensity warfarin (target INR, 1.5 to 2.0). Participants were followed for recurrent venous thromboembolism, major hemorrhage, and death. RESULTS: The trial was terminated early after 508 patients had undergone randomization and had been followed for up to 4.3 years (mean, 2.1). Of 253 patients assigned to placebo, 37 had recurrent venous thromboembolism (7.2 per 100 person-years), as compared with 14 of 255 patients assigned to low-intensity warfarin (2.6 per 100 person-years), a risk reduction of 64 percent (hazard ratio, 0.36 [95 percent confidence interval, 0.19 to 0.67]; P<0.001). Risk reductions were similar for all subgroups, including those with and those without inherited thrombophilia. Major hemorrhage occurred in two patients assigned to placebo and five assigned to low-intensity warfarin (P=0.25). Eight patients in the placebo group and four in the group assigned to low-intensity warfarin died (P=0.26). Low-intensity warfarin was thus associated with a 48 percent reduction in the composite end point of recurrent venous thromboembolism, major hemorrhage, or death. According to per-protocol and as-treated analyses, the reduction in the risk of recurrent venous thromboembolism was between 76 and 81 percent. CONCLUSIONS: Long-term, low-intensity warfarin therapy is a highly effective method of preventing recurrent venous thromboembolism.
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“Furthermore, trials in that analysis were published before 2004, whereas since then additional prospective studies have reported on the risk for recurrent VTE after discontinuation of anticoagulant treatment in patients with a first episode of unprovoked VTE, with several of these studies having followed patients beyond 24 months and some up to 10 years.9 10 11 12 13”
From Long term risk of symptomatic recurrent venous thromboembolism after discontinuation of anticoagulant treatment for first unprovoked venous thromboembolism event: systematic review and meta-analysis (2019) · cites this paper as [9]
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Metadata
- Authors
- Ridker, P. M., Goldhaber, S. Z., Danielson, E., Rosenberg, Y., Eby, C. S., Deitcher, S. R., Cushman, M., Moll, S., Kessler, C. M., Elliott, C. G., Paulson, R., Wong, T., Bauer, K. A., Schwartz, B. A., Miletich, J. P., Bounameaux, H., & Glynn, R. J.
- Affiliations
- Brigham and Women's Hospital (US)
- National Institutes of Health (US)
- Washington University in St. Louis (US)
- Cleveland Clinic (US)
- University of Vermont (US)
- University of North Carolina at Chapel Hill (US)
- Georgetown University Medical Center (US)
- LDS Hospital (US)
- Altru Health System (US)
- St. Boniface Hospital (CA)
- Beth Israel Deaconess Medical Center (US)
- University Hospital of Geneva (CH)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2003-04-10
- Volume
- 348
- Issue
- 15
- Pages
- 1425-1434
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2112757583
- Cited by
- 808
- References
- 29
- Citations by year
- 2026: 3 · 2025: 9 · 2024: 5 · 2023: 7 · 2022: 10 · 2021: 13 · 2020: 16 · 2019: 23 · 2018: 16 · 2017: 19 · 2016: 25 · 2015: 24 · 2014: 45 · 2013: 38 · 2012: 44
- FWCI
- 53.42
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Internal Medicine › Venous Thromboembolism Diagnosis and Management
- Health Sciences › Medicine › Hematology › Blood Coagulation and Thrombosis Mechanisms
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Keywords
- recurrent venous thromboembolism, long-term anticoagulation, idiopathic venous thromboembolism, major bleeding, inherited thrombophilia, international normalized ratio, benefit-risk balance
- MeSH terms
- Aged, Anticoagulants, Double-Blind Method, Drug Administration Schedule, Female, Hemorrhage, Humans, Male, Middle Aged, Pulmonary Embolism, Risk, Thromboembolism, Warfarin, International Normalized Ratio, Venous Thrombosis, Stroke, Secondary Prevention
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